This Section explains the appeals process for providers whose SoonerCare contracts have been suspended/terminated by the OHCA for cause.  Those providers whose contracts have been affected by other OHCA actions cannot request an appeal of those measures. Contracts terminated or suspended for cause are either timed terminations (30, 60, or 90 day) or immediate terminations/suspensions. Paragraphs (1) and (2) apply to timed terminations/suspensions and paragraph (3) applies to immediate terminations.

• (1) Procedure for suspending/terminating provider's contract.
  • (A) Notice of proposed suspension or termination.  The OHCA will provide notice to the medical services provider of the proposed suspension or termination of provider contract.  The written notice of suspension/termination will state:
    • (i) the reasons for the proposed suspension/termination;
    • (ii) the date upon which the suspension/termination will be effective; and
    • (iii) a statement that the medical services provider has a right to review prior to the suspension/termination of the provider's contract (refer to subparagraph (B) of this paragraph).
  • (B) Right to review prior to suspension/termination of provider contract.  Before the medical services provider's contract is suspended or terminated, the OHCA will give the medical services provider the opportunity to submit documents and written arguments against the suspension/termination of the provider's contract.
  • (C) Notice of suspension or termination.
    • (i) After the review of the medical services provider's written response, the OHCA will make a final administrative decision subject to a post-suspension or termination hearing.
    • (ii) After the review of the medical services provider's written response, the OHCA will make a final administrative decision subject to a post-sanction hearing.  Should the OHCA decide not to suspend or terminate the provider's contract, the medical services provider will be notified of the reasons for the decision.
    • (iii) Should the OHCA make a decision to suspend or terminate the medical services provider's contract, the OHCA will send a notice stating:
      • (I) the reasons for the decision;
      • (II) the effective date of the suspension or termination of the contract;
      • (III) the medical services provider's right to request a post-suspension or termination hearing; and
      • (IV) the requirements and procedures for reinstatement.
• (2) Post-suspension/termination hearing.  After the effective date of the suspension or termination of the provider's contract, the medical services provider is entitled to receive a post-suspension or termination hearing.  The hearing committee for the OHCA will be comprised of three members of the OHCA and two other members as appointed.  The representative who investigated the case will not be a representative if an investigation was initiated or completed.
  • (A) After the provider's request for the post-suspension/termination hearing is made, a hearing date will be established.  A certified letter will be sent to the provider giving notification of the hearing date and naming the contact person.  The contact person will answer procedural questions about the hearing.
  • (B) Ten days prior to the hearing, the medical services provider will submit a brief written statement detailing the evidence which will be presented by the provider at the hearing.  Such statement must detail the facts which will be refuted by the provider.  The purpose of the hearing will be limited to issues raised in the letter of suspension or termination as the cause of suspending or terminating the provider contract.
  • (C) The provider may be represented by an authorized representative, with documentation to that effect, at the informal hearing and/or the provider may present testimony himself or herself and have witnesses present.
  • (D) At the conclusion of the hearing, a decision will be made by the Hearing Committee.  The provider will be notified in writing of the decision within 20 days of the final day of the hearing.  The decision letter will constitute the agency's final decision regarding the matter.
• (3) Notice of immediate suspension or termination. The process below will be followed in the event of an immediate suspension or termination:
  • (A) A notice described in paragraph (1)(A) will be sent to the provider, except there is no right to review prior to an immediate termination or suspension.
  • (B) A post suspension termination review will be conducted in accordance with paragraph (2) above.